Suicidal Ideation

17 Suicidal Ideation and Behaviors Stephen E. Brock  California State University, University, Sacramento

 Jonathan Sandoval University of California, Davis 

Shelley Hart  California State University, University, Sacramento

I

n 2001 more than 30,000 Americans died by suicide (Anderson & Smith, 2003), and within each of the age groups from 10 to 64 years, suicide ranks within the top 10 leading causes of death. Other forms of non-lethal suicidal behaviors are even more common. In 2002 it was estimated that 132,353 individuals were hospitalized following suicide attempts (Centers for Disease Control and Prevention Prevention [CDC], 2004). However However,, encouraging  encouraging  statistics show that youth suicide rates are currently at their lowest point in 20 years and have been declining  since since 1992 (Lubel (Lubell, l, Swa Swahn, hn, Crosby Crosby,, & Kegler Kegler,, 2004). 2004). Since 1991, the percentage of students who seriously considered suicide also declined (Grunbaum et al., 2004). Still, the U.S. statistics for youth are alarming. Despite the recent decline in youth suicide rates, they are still more than than three three time timess high higher er than than what what they they were were in 1950 1950 (Prag (Prager er,, 2003). 2003). In the Unite United d States States,, suicid suicidee curren currently  tly  ranks as the third leading cause of death in the 10- to 24year-old age group (Centers for Disease Control, 2005). Given these statistics, it is critical that providers of school psychological services understand this phenomenon and be informed about suicide prevention and intervention.

BACKGROUND AND DEVELOPMENT  Although suicidal ideation and the decision to engage in suicid suicidal al behavior behavior is idiosyn idiosyncra cratic tic,, consis consistin tingg of both cumulative cumulative exposure to multiple multiple risk factors and the relative lack of protective protective factors, it is possible possible to evaluate evaluate the

prevalence prevalence of suicidal suicidal behaviors behaviors by groups—age, groups—age, gender, gender, ethnicity, sexual orientation, and access to firearms—and to consider the unique risks associated with each group.

 Age Suicide rates increase as a function of age. Suicide is rare among children under 5 years. On the other hand, older adul adults ts have have the the most most suic suicid idee deat deaths hs of any any grou group p (Anderson & Smith, 2003). The converse is true of the rate of suicide attempts, which is highest among adolescents and young adults and lowest among the elderly  (Hjelmeland et al., 2002).

Gender Females of all races are more likely to report having had suicidal suicidal ideation and are almost twice as likely to attempt suicide (CDC, 2002). However, males of all races are almost five times as likely as females to die by suicide. Males are also significantly more likely than females to attempt suicide impulsively (Simon et al., 2001), whereas females are more likely to tell someone about suicidal thoughts and plans (O’Donnell, O’Donnell, Wardlaw, & Stueve, 2004).

Ethnicity   Among Native American American and Asian American American youth age 25 and under, suicide ranks second among causes of death. Despite a recent decline, the suicide rate among adolescent 225

Children’s Needs III Native American males continues to be the highest of any  group, whereas Caucasian males still have the highest absolute number of suicide deaths, accounting for approximately 70% of suicides. Among adolescent females, the  Asian and Pacific Islander group has the highest suicide rate (Anderson & Smith, 2003).

Sexual Orientation Gay and lesbian youth have been reported to be at increased risk for suicidal behavior when compared to the general population. Studies have suggested a two- to fourfold increased risk for this group (O’Donnell et al., 2004).

 Access to Firearms The availability of firearms is associated with increased suicidal ideation (Bearman & Moody, 2004), and the presence of a gun in the home is associated with a five times greater risk of suicide (Kellermann et al., 1992). Firearms have consistently ranked first among methods of suicide, accounting for nearly three of five youth suicides (American Association of Suicidology, 2003).

PROBLEMS AND IMPLICATIONS It is rare for an individual to suddenly and unexpectedly  commit suicide. Rather, suicide is typically the result of a  relative lack of resiliency factors and an accumulation of  risk. In addition, a suicidal person typically displays warning signs that predict their behavior. Table 1 summarizes these resiliency factors, risk factors, and warning  signs. The absence of resiliency factors and the presence of risk factors do not perfectly predict suicidal ideation and behaviors. However, these variables do signal the need to increase vigilance for suicide warning signs.

Resiliency Factors The presence of resiliency factors appears to mitigate the potential of risk factors to generate suicidal ideation and behaviors (CDC, 2004). Perhaps the most powerful resiliency factors exist within interpersonal systems, including  family (e.g., feeling supported by, and having an open line of communication with, family members; O’Donnell et al., 2004) and peers (e.g., supportive and dense social networks; Rutter & Soucar, 2002). To the extent these systems are present and functional, they may  226

protect individuals from suicide. To the extent they are absent or dysfunctional, they may result in an increased vulnerability to suicidal ideation and behaviors.

Risk Factors In addition to a lack of resiliency factors, the following  risk factors may also signal the need to increase vigilance for suicide warning signs.

Prior suicide attempts.  A previous suicide attempt is one of the most significant predictors of future suicidal behavior. In one study, at a 3-month follow-up of adolescents who had attempted suicide, 12% had made another attempt (Spirito, Valeri, Boergers, & Donaldson, 2003).  A long-term follow-up of first-time suicide attempters with depression found that 38% had died by suicide within 5 years and 8% had made at least one additional ˚dvik, 2003). In attempt after more than 10 years (Bra  assessing this risk factor, it is important to make a distinction between suicidal and other self-injurious behaviors. For example, what is commonly referred to as cutting behavior is not necessarily suicidal (see chapter 72, ‘‘Self-Mutilation’’). For a prior behavior to be considered a suicide attempt, the individual must have had conscious thoughts of ending his or her own life.

History of psychopathology.   Over 90% of people who engage in suicidal behaviors have a psychiatric disorder (Seeley, Rohde, Lewinsohn, & Clarke, 2002). Mood disorders, specifically depression, are the most common diagnoses, followed by substance abuse, disruptive behavior, and anxiety disorders (Bearman & Moody, 2004; Seeley et al.; Simon et al., 2001). It is estimated that the risk of suicide among individuals with major depression is 20 times greater than that of the general population (American Association of  Suicidology, 2004), and a greater intent to die has been reported among individuals who are more significantly  depressed (Haw, Hawton, Houston, & Townsend, 2003). Individuals diagnosed with depression in childhood, with chronic and frequent depressive episodes, and with more depressive symptoms have been shown to be more likely to make multiple suicide attempts (Spirito et al., 2003). Although typically associated with depression, the symptom of hopelessness appears to be valuable as a stand-alone predictor of suicidal ideation and behaviors (Spirito et al.). Psychopharmacological treatments for depression have also been suggested to be a risk factor for suicidal

Chapter 17: Suicidal Ideation and Behaviors Table 1

Resiliency Factors, Risk Factors, and Warning Signs  Resiliency Factors 

Family support and cohesion Good family communication

General life satisfaction Ties to neighborhood and community 

Parent involvement and engagement

High self-esteem

Peer support and close social networks

Easy access to mental health resources

School connectedness

Restricted access to lethal means (guns)

Cultural or religious beliefs that discourage suicide

Feeling that one has a purpose in life

 Adaptive coping and problem-solving skills

Effective medical and mental health care

Good conflict-resolution skills Risk Factors  Previous suicide attempt(s)

Mental disorder (particularly depression)

 Alcohol/substance abuse Family history of suicide

Comorbid disorders Hopelessness/helplessness

Impulsive or aggressive behavior

Self-injurious behavior (e.g., cutting)

Sexual and/or physical abuse

Easy access to lethal suicide methods

Impulsive or aggressive tendencies

Physical illness

Isolation

Significant others who have died by suicide

Barriers to access to mental health treatment

Relational, social, work, or financial loss

Cultural or religious beliefs that allow suicide

Local epidemics of suicide

Unwillingness to seek mental health assistance Warning Signs  Displaying overt suicidal statements and/or behaviors

Increased use/abuse of alcohol and/or drugs

Giving indirect clues of suicidal thoughts and plans

Making abrupt changes in appearance

Putting personal affairs in order

 Altering patterns of sleeping or eating  Demonstrating inability to concentrate or think rationally 

Giving away prized possessions Talking about suicide and death Talking about having no reason to live

 Acting happy suddenly and unexpectedly 

 Withdrawing from family and friends

Running away from home

Showing improvement in mood after a period of depression

Losing interest in once pleasurable activities Showing drastic changes in behavior or mood Sources . ASA (2004), Capuzzi (2002), and  The Surgeon General’s Call to Action to Prevent Suicide . Washington, DC: Author. U.S. Public Health Service (1999)

ideation and behaviors. Antidepressants such as Paxil and Prozac have been reported to increase suicide risk, especially during the first few days and weeks of treatment (Jick, Kaye, & Jick, 2004). Thus, students with depression who have recently been prescribed an antidepressant should be closely monitored for the emergence

of suicidality (U.S. Food and Drug Administration, 2004).

Biology.   Twin studies have suggested a link between genetic factors and youth suicide attempts, with the combination of genetic and environmental factors accounting  227

Children’s Needs III for 33% to 73% of the variance in the risk for suicidal behavior (Glowinski et al., 2001). Other biological risk  factors may exist within the central nervous system. For example, low levels of serotonin metabolite in the cerebrospinal fluid have been indicated as a significant correlate of current and future suicidal behavior (Goldsmith, Pellmar, Kleinman, & Bunney, 2002).

Family.  Dysfunctional family environments have been studied frequently in suicide research. Low levels of  parental support and involvement (Bearman & Moody, 2004), a parental history of mental disorders such as substance abuse (King et al., 2001), and both physical and sexual abuse (Glowinski et al., 2001) have been significantly associated with suicidal ideation and behaviors.

Situations.   The situations that lead to suicidality  include stressors that consume available resources and produce an overwhelming sense of loss. For example, among adolescents, a relationship breakup or a rejection resulting in questions about an individual’s sexual orientation may generate such feelings of loss and hopelessness (Moscicki, 1995). Although these events may appear to be the precipitating factor that triggers a suicide, in most cases these events typically have built upon a series of  other circumstances and risk factors (Ramsay, Tanney, Lang, & Kinzel, 2004). Nevertheless, research has suggested some specific situations that increase risk for suicidal ideation and behaviors. These include (a) exposure to the suicidal behavior of a family member or friend, (b) social isolation and lack of connection to school, and (c) the presence of a firearm in the home (Bearman & Moody, 2004).

 Warning Signs of Suicidal Ideation and  Behaviors  Whereas risk factors suggest the need to be vigilant for signs of suicidal ideation and behaviors, warning signs imply their presence. Warning signs are the ways in which an individual communicates distress and signals the possibility of suicidal ideation. Even individuals who engage in impulsive suicide attempts typically give some indication of their plans (Simon et al., 2001). Especially  when combined with risk factors, warning signs require direct inquiry about the presence of suicidal ideation (i.e., asking the question: ‘‘Are you thinking about suicide?’’) and may indicate the need for immediate suicide intervention. Table 1 provides a list of both direct and indirect suicide warning signs. 228

 ALTERNATIVE ACTIONS FOR  PREVENTION Suicidal ideation and behaviors have a tremendous effect on learning. Within a typical high school classroom of  30 students, it is likely that three students have made a  suicide attempt within the past year (CDC, 2004). These students are psychologically unavailable for academic instruction and their behavior may be negatively affecting other non-suicidal students in the class (Brock, Lazarus, & Jimerson, 2002). Furthermore, districts have been found liable by the courts when they failed to provide suicide prevention programs and adequate supervision of suicidal students (Lieberman & Davis, 2002). Thus, well-developed plans are needed for suicide prevention, intervention, and postvention (i.e., the response to a completed suicide).

Suicide Prevention and Awareness Curricula  Curriculum programs typically target the entire student body. In general, these programs strive to raise the overall responsiveness within the at-risk student’s environment. In doing so, they recognize that peers are an important part of an adolescent’s life, and it is more likely that a  youth will share concerns with a peer rather than an adult. Goals of curriculum programs include increasing  awareness of the problem, providing knowledge about the behaviors associated with suicide, and describing the resources available to help. These programs have not always been viewed as effective. Concerns have included the observation that very few adolescents attending these programs commit suicide (Shaffer, Garland, Gould, Fisher, & Trautman, 1988) and that most students already hold accurate views of suicide (Shaffer, Garland, & Whittle, 1987). It has been argued, therefore, that prevention resources should be allocated to programs for at-risk youngsters, instead of targeting the entire student body.  A second concern is the tendency of these programs to normalize suicidal behavior. Garland, Shaffer, and  Whittle (1989) reported that many curriculum programs employ a  stress model  of suicide (i.e., suicide as a response to stress or pressures that could happen to anyone) rather than a   mental illness model  (i.e., suicide as a consequence of mental illness). This view is contrary to the fact that suicide is typically associated with emotional disturbance and may increase the tendency to view suicidal behavior as a mainstream solution to problems.

Chapter 17: Suicidal Ideation and Behaviors  A final concern regarding student body programs is their effect on suicidal students. Garland et al. (1989) suggest that students who had made suicide attempts and had attended a suicide prevention program did not appear to respond as favorably to these programs as did nonattempters. When compared with suicide attempters who did not attend a suicide prevention program, suicide attempters who were program participants were less likely to reveal suicidal intentions, less likely to believe that a mental health professional could help them, and more likely to view suicide as a reasonable solution. Recently developed programs have responded to these potential shortcomings and have been shown to be promising. Specifically, the Signs of Suicide (SOS) program is an approach that incorporates a curriculum component with a brief screening for depression and other suicide risk factors. The goal is to make automatic the ‘‘action steps’’ taken when confronting suicide (i.e.,  Acknowledge, Care, and Tell, or ACT). The SOS program subscribes to a mental illness model. Making use of  a randomized control group model, a recent study demonstrated that the SOS program significantly lowered self-reported suicide attempts over a 3-month period. In addition, relative to the control group, evaluation data  suggested that SOS program participants had greater knowledge and more adaptive attitudes about depression and suicide (see Recommended Resources; Aseltine & DeMartino, 2004). In addition, programs that promote resiliency factors are often reported to be helpful in the prevention of suicidal behaviors (Edwards & Holden, 2001). These may  include programs that enhance problem-solving, decisionmaking, and coping skills. Examples of such programs include   I Can Problem Solve   (Aberson & Shure, 2002) and social skills training (Elliott, McKevitt, & DiPerna, 2002). Because of developmental issues and the fact that suicide is rare among children, elementary schools’ suicide prevention efforts should focus more exclusively on these types of prevention programs (Capuzzi, 2002).

School Gatekeeper Training  Education of school staff members is frequently identified as an essential component of any prevention program (Helsel, 2001). Teachers are the school professionals who spend the most time with at-risk students. It is thus crucial for them to be able to identify and bring these individuals to the attention of school psychologists and counselors. A good practice for school districts is to provide staff with periodic training 

sessions, using suicide intervention scenarios and roleplaying to apply the knowledge and to practice skills. The  Technical Assistance Sampler on School Interventions  to Prevent Youth Suicide  (Center for Mental Health in Schools at UCLA, 2003) provides a wealth of information on suicide prevention, intervention, and postvention and identifies specific gatekeeper training programs available throughout the country.

Suicide Risk Screening  It is possible to efficiently and briefly (in less than 15 minutes) screen an individual for suicide risk (Gutierrez, Osman, & Kopper, 2000). An example of such a screening tool is the  Suicidal Ideation Questionnaire  (Reynolds, 1988). These screenings rarely yield false negatives but will frequently yield false positives. Thus, a second-stage evaluation of all positive results is required. Limitations of school-wide screening include the fact that suicidal ideation waxes and wanes over time and circumstances. Thus, multiple screenings may be necessary to capture all potentially at-risk students. An additional limitation is the acceptability of large-scale suicide risk screenings. Survey results suggest that school psychologists rate school-wide screenings as unacceptable (relative to curriculum programs and gatekeeper training) primarily due to their intrusiveness. However, the authors of this study  also speculated that these screenings may be viewed as relatively unacceptable due to the time and effort they  require (Eckert, Miller, DuPaul, & Riley-Tillman, 2003). Given these difficulties, school-wide screening  may be most practical and acceptable when there is concern regarding suicide contagion.

Restriction of Access to Lethal Means  Although an area of controversy, restrictive gun control laws are associated with lower suicide rates (Carrington & Moyer, 1994). In particular, study findings have suggested that these regulations would be helpful in reducing  the rate of suicide in the 15- to 24-year-old age group (Sloan, Rivara, Reay, Ferris, & Kellermann, 1990).

 ALTERNATIVE ACTIONS FOR  INTERVENTION Despite the best of prevention efforts, suicidal ideation and behaviors will continue to occur. Thus, schools must 229

Children’s Needs III Table 2

General Suicide Intervention Procedures for School Staff  

1. Stay with the student.  A suicidal student should never be left alone. A staff member should maintain constant visual contact with the student until help is obtained. This is true regardless of whether the student has made a direct or indirect threat. Until a suicide risk assessment is conducted, every student who appears to have suicidal ideation should be viewed as being at risk for a suicidal behavior. 2. Do not allow the student to leave the school.  A student who has threatened suicide should not be allowed to leave school until the appropriate personnel (ideally a school psychologist or counselor) have conducted a risk assessment and until adequate supervision has been ensured. If a student does attempt to leave, staff members should ask the student to stay but should not do anything that puts themselves, or other students or staff members, in danger. If the student will not stay when requested, the police should be called. 3. Do not promise confidentiality . All staff members have a legal and ethical responsibility  not  to honor confidentiality when a student is threatening harm to self or others. No matter how much a student implores, a suicide plan must not be kept secret. It is better to have the student angry and alive than dead because a confidence was maintained. 4. Determine if the student will relinquish the means . If the student has the means to attempt suicide readily accessible, staff members should request that the student relinquish the means. They should not force the student or put themselves or others in danger. If a student refuses to voluntarily relinquish the means of a threatened suicide, then the police should be called. 5. Take the student to a prearranged room. As soon as possible, the student should be taken to a prearranged, nonthreatening room away from other students. There should be a phone in the room and another adult close by. 6. Notify the designated reporter.  Schools should have a designated reporter (this would likely be a school psychologist or counselor) who will receive and immediately act upon all reports of suicide threats. It is important that this person is accessible and able to quickly respond to the suicide threat. The actions of the designated reporter are reviewed in Table 3. 7. Notify the principal.  The principal should be made aware of any suicidal ideation or behavior. Given the high stakes and the principal’s responsibilities for the school, it is essential that the principal be aware that a student is being assessed for suicide risk. 8. Inform the youth of actions taken.  Before leaving a potentially suicidal student with the designated reporter, it is important to let the student know that help has been called and to describe what will happen next. The student should be told that his or her parents or guardians will need to be contacted. If the student is resistant to this idea, that information should be relayed to the designated reporter. If it is suspected that a student’s resistance to parental contact is a consequence of abuse, a referral to child protective services must be made. Though staff  members cannot promise that parents will not be informed of the suicidal threats, it would be appropriate to let a suicidal student know  his or her concerns have been heard and are understood.

develop procedures for responding to the presence of a  suicide threat and the occurrence of a suicidal behavior.

Suicide Intervention Goals of suicide intervention include ensuring student safety, assessing and responding to suicide risk, determining needed services, and ensuring appropriate care. Both general staff procedures and specific risk assessment and referral procedures need to be developed. An example of  general staff procedures is provided in Table 2. These procedures should be followed whenever a staff member suspects a student is at risk for a suicidal behavior and 230

identify how such a student will be brought to the attention of a ‘‘designated reporter’’ (Davis & Sandoval, 1991). A designated reporter is typically a school psychologist or counselor who has been trained to conduct suicide risk assessment and who is competent to make referral decisions. A model risk assessment and referral procedure is provided in Table 3.

Suicide Postvention It has been estimated that the number of individuals in the United States who have had close relationships with suicide victims (suicide survivors) is over 4 million, and

Chapter 17: Suicidal Ideation and Behaviors Table 3

Risk Assessment and Referral Procedures 

1. Discuss the reasons for referral with the referring staff member and begin to establish rapport with the student suspected to be suicidal. 2. Conduct an assessment to determine the student’s risk of engaging in a suicidal behavior. The risk assessment should include the following: a. Identify suicidal ideation. i. Once the student has been engaged (through a demonstration of empathy, respect, and warmth), identify suicidal intent through direct questioning (e.g., ‘‘Sometimes when people have had your experiences and feelings they have thoughts of suicide. Is this something that you’re thinking about?’’). ii. If thoughts of suicide are not present, a suicide intervention is not needed, but support and assistance with the student’s referring  concerns will likely be required. iii. If thoughts of suicide are present, continue to assess the student’s risk of acting upon such ideation. b. Assess suicide risk in the following areas. i. Current suicide plan.  Directly inquire about the presence of a plan (e.g., ‘‘Do you have a plan for how you might act on your thoughts of suicide?’’). The greater the planning, the greater the risk. Other specific questions to ask include (a) ‘‘How might you do it?’’ (b) ‘‘How soon are you planning on suicide?’’ and (c) ‘‘How prepared are you to commit suicide?’’ (access to means of  attempt). ii.   Pain.  Directly inquire about the degree to which the individual is desperate (e.g., ‘‘Does your physical or emotional pain feel unbearable?’’). The more unbearable the pain, the greater the risk. iii.   Resources. Directly inquire about the individual’s perceptions of being alone (e.g., ‘‘Do you have any resources or reasons for living?’’). The more ‘‘alone,’’ the greater the risk. iv. Prior suicidal behavior.  Directly inquire about the individual’s history of suicidal behavior (e.g., ‘‘Have you or anyone close to you ever attempted suicide before?’’). The more frequent the prior suicidal behavior the greater the risk. v. History of mental illness. Directly inquire about the individual’s mental health history (e.g., ‘‘Have you ever had mental health care?’’). Depression, schizophrenia, alcohol and substance abuse, trauma, and borderline personality disorders are particular concerns. 3. Consult with fellow staff members regarding risk assessment results. A school-based suicide risk assessment should never be done alone. 4. Consult with community mental health professionals. These are typically the individuals to whom the suicidal student would be referred. 5. Use risk assessment information and consultation guidance to develop an action plan. Action plan options are as follows: a.  Extreme Risk. If the student has the means of his or her threatened suicide at hand and refuses to relinquish it, follow these procedures: i. Call the police. ii. Calm the student by talking and reassuring until the police arrive. iii. Continue to request that the student relinquish the means of the threatened suicide and try to prevent the student from harming  himself or herself. When doing so, make certain that such requests do not place anyone else in danger. iv. Call the parents and inform them of the actions taken. b. Crisis Intervention Referral. If the student’s risk of harming himself or herself is judged to be moderate to high (i.e., there is a probability  of the student acting on suicidal thoughts, but the threat is not immediate), then follow these procedures. i. Determine if the student’s distress is the result of parent or caregiver abuse, neglect, or exploitation. If so, contact child protective services instead of a parent or caregiver. ii. Meet with the student’s parents (or child protective services). iii. Make appropriate referrals. iv. Determine what to do if the parents are unable or unwilling to assist with the suicidal crisis (e.g., call the police).

(Continued)

231

Children’s Needs III Table 3   Continued  c.  Low Risk. If the student’s risk of harming himself or herself is judged to be low (i.e., although the student has thoughts of suicide, the risk assessment suggests a very low probability of engaging in a suicidal behavior), then follow these procedures. i. Determine if the student’s distress is the result of parent or caregiver abuse, neglect, or exploitation. If so, contact child protective service instead of a parent or caregiver. ii. Meet with the student’s parents (or child protective services). iii. Make appropriate referrals. 6. When making referrals, protect the privacy of the student and family. 7. Follow up with the hospital or clinic to ensure that the student is receiving the appropriate care. Note . Source of risk assessment variables: R. F. Ramsay, B. L. Tanney, W. A. Lang, & T. Kinzel. (2004).  Suicide Intervention Handbook  (10th ed.). Calgary, AB: LivingWorks.

that number is growing by 180,000 per year (Jobes, Luoma, Hustead, & Mann, 2000). When taking into account those who have had relationships with individuals exhibiting other suicidal behaviors, estimates of the number of people affected by suicidality become staggering. These facts point to the need for schools to be prepared to respond to the aftermath of suicidal behavior. This response is referred to as  suicide postvention . Postvention assists in the identification of individuals who are having difficulty coping with a suicide and facilitates adaptive coping. Following a suicide, it is not unusual for some students and staff members to enter into a crisis state. In addition to the emotions felt after other types of loss, this state may consist of a set of  unique emotional reactions, such as guilt, anger, shame, and isolation associated with the stigma attached to suicide (Brock, 2002). An additional postvention concern is the possibility of contagion. Although such imitative behavior accounts for only an estimated 1% to 3% of all adolescent suicides (Moscicki, 1995), the potential to imitate suicidal behavior appears to be a unique issue for adolescents (Askland, Sonnenfeld, & Crosby, 2003).  Jobes et al. (2000) describe suicide postvention’s guiding  principles. They emphasize the importance of not dramatizing or glorifying the suicide. They also point out that doing nothing can be as dangerous as doing too much and that students cannot be helped until school staff are helped. To effectively provide suicide postvention, schools should form a suicide postvention (or crisis intervention) team that will follow a specific protocol. The following  describes the essential elements of the postvention protocol developed by Brock (2002). Ideally, different staff  232

members would be working on several of these tasks simultaneously.

Verify that a death has occurred. The legal classification of a death as a suicide is complex and is usually made by medical examiners; therefore, it is essential to avoid labeling any death a suicide, even what may seem to be an obvious suicide, until an official determination is made.

 Mobilize the crisis intervention team.   Successful suicide postvention requires a team effort, with specific postvention response roles carried out by specific individuals. Each element of this postvention protocol should be addressed as part of a team effort.

 Assess the suicide’s impact on the school and estimate the level of postvention response.   As soon as the death is verified and the facts are known, the school should assess the effects of the loss on the student body.  A suicide’s impact is assessed by estimating the number of students affected by the death. Proximity is an important way of assessing such impact, including physical and emotional proximity to the current suicide, and temporal proximity to prior instances of suicidal behavior. Variables to consider when estimating the number of students affected by a suicide are given in Table 4. To the extent these variables are present, the suicide’s impact will be greater.

Notify other involved school personnel.   The crisis team should next contact other school personnel who will likely be affected by the death or will participate in the response. Assessment of impact on these individuals

Chapter 17: Suicidal Ideation and Behaviors Table 4

Variables to Consider When Assessing the Impact of a Suicide on a School 

Risk Factor

Examples

Facilitated the suicide

1. Were involved in a suicide pact. 2. Helped write the suicide note. 3. Provided the means of the suicide. 4. Knew about and did not try to stop the suicide.

Failed to recognize the suicidal intent

1. Observed events that were later learned to be signs of the impending suicide. 2. Did not take a suicide threat seriously. 3. Had been too busy to talk to a person who committed suicide and had asked for help.

Believe they may have caused the suicide

1. Feel guilty about things said or done to the victim before the suicide. 2. Recently punished or threatened to punish the person who committed suicide for some misdeed.

Had a relationship or identify with the person who committed suicide

1. Were mentioned in the suicide note. 2. Were relatives, best friends, or self-appointed therapists of the person who committed suicide. 3. Identify with the situation of the person who committed suicide. 4. Have life circumstances that parallel those of the suicide victim.

Have a history of prior suicidal behavior

1. Have previously attempted or threatened suicide. 2. Have family members, acquaintances, or role models who have died by  suicide.

Have a history of psychopathology 

1. Have poor baseline mental health. 2. Have substance abuse problems. 3. Have a history of impulsive or violent behavior directed either toward self or others.

Show symptoms of helplessness, hopelessness, or both

1. Are feeling desperate and now consider suicide a viable alternative. 2. Feel powerless to change distressing life circumstances. 3. Are depressed.

Have suffered significant life stressors or losses

1. Had family members or acquaintances that have died by accident or homicide. 2. Had someone they were close to die violently. 3. Had recently broken up with a girlfriend or boyfriend. 4. Have been disrupted by changes in residence, schools, or parental figures.

Note . Adapted from ‘‘The School Psychologist’s Role in Suicide Prevention.’’ By J. Sandoval, & S. E. Brock, (1996),  School Psychology Quarterly, 11, 169–185. Used by permission of publisher.

233

Children’s Needs III or school sites, and estimated response needs, should be considered when evaluating whom to contact.

Contact the family of the suicide victim.  The goals of this contact include expression of the school’s sympathy and, if needed, offers of postvention assistance. The family may be helpful in identifying others who may need crisis intervention (e.g., the victim’s close friends).

Determine what information to share about the  death.  An announcement regarding the death should be made as soon as possible. Delay fuels rumors that can be damaging and difficult to dispel. Because not all of the facts may be immediately available, several communications may be needed (e.g., before and after the death is certified as a suicide). Students could be provided the basic facts about the death, but excessive details should be avoided. Postvention should avoid glorifying or sensationalizing the death while at the same time providing a  timely flow of accurate information.

Determine how to share information about the  death.   Options for sharing information with students include written bulletins, letters, phone calls, classroom presentations and discussions, and individual conferences. Regardless of the method all students should receive the information at the same time. A communication to the parents must also be prepared.  Working with the media is an important postvention task. To minimize the risk of suicide contagion, the CDC (2004) provides recommendations for the media when reporting suicide deaths. Specifically, they recommend that the media (a) downplay the death, such as by not placing the word suicide in the headline, not including a  picture of the individual, and placing the article on an inside page, if it’s necessary to report it at all; (b) not romanticize the death; (c) discourage opportunities for students to identify with the individual and not illuminate the pathological aspects of the suicide act; and (d) provide resources for individuals who may be at risk.

Identify students significantly affected by the suicide and initiate referral procedures.   During the crisis intervention team’s assessment of the impact of the death on the school, high-risk individuals will be identified. Physical and emotional proximity to the current suicide and temporal proximity to prior suicides are the primary concerns when identifying students who may  need crisis intervention. 234

Conduct a faculty planning session.  In addition to the initial staff meeting, the school should hold other meetings to provide the staff with updated information regarding the death. At these meetings, teachers should be informed that they are a vital component of the postvention response. Guidance should be offered regarding  the potential need to suspend normal instruction for the postvention. However, at the same time it should be remembered that keeping to as normal a schedule as possible is reassuring to many. During this staff meeting, teachers should also be given permission to feel uncomfortable about discussing the suicide with their students. Such feelings may result in some staff members not being  able to provide students with needed support and guidance, and the school should provide alternative opportunities for helping students cope.

Initiate crisis intervention services.  Planned interventions should be implemented (e.g., classroom activities, group sessions, individual sessions, parent meetings, or staff meetings) and referrals made to outside agencies. Typical intervention tasks include (a) facilitating the expression and acceptance of emotions over the loss through both verbal and nonverbal communications while ensuring that students do not identify with the person who committed suicide, (b) refraining from romanticizing or glorifying the person’s behavior or circumstances, and (c) discouraging dwelling on real or imagined guilt. To prevent students’ identification with the suicide, crisis counselors should point out how the survivors are different from the person who committed suicide and discuss how suicide was a poor choice (e.g., how feelings and situations can change quickly, what the individual will miss out on in life). Postvention providers can prevent the glorification of the act by not making the suicide seem exciting or the person who committed suicide admirable.

Conduct daily planning sessions.  Planning sessions should be held to evaluate the progress of the postvention as well as to make plans for the following day. These sessions also provide ongoing debriefing opportunities for the crisis team.

 Memorialize.  After a crisis event, many people feel the need to express their grief, say goodbye, and do something as a memorial. Working together on a memorial can help survivors focus their grief, fears, and anger constructively. However, when choosing memorials following a suicide, postvention providers should take

Chapter 17: Suicidal Ideation and Behaviors Table 5

Memorial Activities Following a Suicide: A List of ‘‘Dos’’ and ‘ Don’ts’’  DO

Do something to prevent other suicides from happening.

DON’T

 

 

Don’t   make special arrangements to send all students from school to funerals.

Do develop living memorials (e.g., student assistance programs that help other students cope with feelings and problems).

Don’t   have memorial or funeral services at school.

Do allow any student, with parental permission, to attend the funeral.

Don’t  stop classes for a funeral.

Do encourage affected students, with parental permission, to attend the funeral.

Don’t   put up plaques in memory of the suicide victim.

Do mention to families and ministers the need to distance the person who committed suicide from survivors to avoid glorifying the suicide act.

Don’t   dedicate yearbooks, songs, or sporting events to the person who committed suicide. Don’t   fly the flag at half-staff. Don’t   have a moment of silence in all-school assemblies. Don’t   have mass assemblies focusing on the suicide victim.

Note . Adapted from ‘‘The School Psychologist’s Role in Suicide Prevention.’’ By J. Sandoval, & S. E. Brock, (1996),  School Psychology Quarterly, 11, 169–185. Used by permission of publisher.

particular care to not romanticize the suicide. Table 5 provides a list of dos and don’ts regarding memorial activities following a suicide.

 Evaluate the postvention response. This is an opportunity to help interveners cope with the crisis. The goals are to review and evaluate the postvention response, as well as to provide an opportunity for crisis interveners to receive support and to continue to deal with their own emotions and reactions. One final point should be made. If there is no chance of students becoming aware of a death that is a  suicide, it is not necessary to report the situation to them or to provide crisis intervention services. Suicide is only  contagious if other people know about it. If knowledge of suicidal behavior can be kept out of a school building, it is probably best to do so. However, the worst-case scenario is for students to know of a suicide and to have the school pretend that it did not occur.

SUMMARY  Suicide is a reality in U.S. public schools. Prevalence data suggest that one suicide within a 5-year period and

somewhere around 170 suicidal acts occur each year in a typical high school (Davis & Sandoval, 1991). Many  of these incidents will not come directly to the school’s attention. Suicidal behavior is a problem that diligent school psychologists, in partnership with other school personnel and community-based professionals, can do something about. This chapter has presented strategies for prevention, intervention, and postvention in the hope that readers will be stimulated to seek further education on this topic and be better prepared for suicidal crises. To that end, the following resources are recommended.

RECOMMENDED RESOURCES Books and Other Printed Material Hawton, K., & van Heeringen, K. (Eds.). (2002). The  international handbook of suicide and attempted suicide.  New York: Wiley. This is a comprehensive and authoritative compilation of the incidence of suicide and attempted suicide, risk factors, and prevention and intervention for suicide behaviors.. 235

Children’s Needs III Maris, R. W., Berman, A. L., & Silverman, M. M. (2000).   The comprehensive textbook of suicidology. New York: Guilford Press.

 Anderson, R. N., & Smith, B. L. (2003). Deaths: Leading  causes for 2001.  National Vital Statistics Report, 52 (9), 1–47.

The foundations of suicidology are covered, along  with theory, research, and clinical applications.

 Aseltine, R. H., & DeMartino, R. (2004). An outcome evaluation of the SOS suicide prevention. American Journal of   Public Health, 94,  446–451. Retrieved August 2, 2005, from http://www.mentalhealthscreening.org/downloads/ sites/docs/sos/AJPHarticle.pdf 

 Websites http://www.save.org  Suicide Awareness/Voices of Education (SAVE) offers information on prevention, postvention, coping, and depression, as well as links to other websites. It is a good starting point.

http://www.suicidology.org   American Association of Suicidology is an informative website by the organization that publishes the journal  Suicide and Life-Threatening Behaviors . Many articles and fact sheets are available for download, and the site has many links to other organizations.

http://www.nopcas.com National Organization for People of Color Against Suicide (NOPCAS) is an organization whose goal is to bring awareness to minority communities. The website offers articles and links.

http://www.mentalhealthscreening.org/sos_highschool  This website provides access to the SOS Signs of  Suicide¤  Program. SOS is a nationally recognized, easily implemented, cost-effective ($200) program of  suicide prevention for secondary school students.

REFERENCES  Aberson, B., & Shure, M. (2002). Problem-solving training as a form of crisis prevention. In S. E. Brock, P. J. Lazarus, & S. R. Jimerson (Eds.),  Best practices  in school crisis prevention and intervention  (pp. 109– 130). Bethesda, MD: National Association of School Psychologists.  American Association of Suicidology. (2003).  Youth suicide fact sheet.   Retrieved June 2, 2004, from http:// www.suicidology.org   American Association of Suicidology. (2004).  Some facts  about suicide and depression.  Retrieved June 2, 2004, from http://www.suicidology.org  236

 Askland, K. D., Sonnenfeld, N., & Crosby, A. (2003). A  public health response to a cluster of suicidal behaviors: Clinical psychiatry, prevention and community  health.  Journal of Psychiatric Practice, 9,  219–227. Bearman, P. S., & Moody, J. (2004). Suicide and friendships among American adolescents.  American Journal  of Public Health, 94,  89–95. ˚dvik, L. (2003). Suicide after suicide attempt in Bra  severe depression: A long-term follow-up.   Suicide  and Life-Threatening Behavior, 33,  381–388. Brock, S. E. (2002). School suicide postvention. In S. E. Brock, P. J. Lazarus, & S. R. Jimerson (Eds.),  Best   practices in school crisis prevention and intervention (pp. 211–223). Bethesda, MD: National Association of School Psychologists. Brock, S. E., Lazarus, P. J., & Jimerson, S. R. (Eds.). (2002).   Best practices in school crisis prevention and  intervention Bethesda, MD: National Association of  School Psychologists. Capuzzi, D. (2002). Legal and ethical challenges in counseling suicidal students.   Professional School  Counseling, 6,  36–46. Carrington, P. J., & Moyer, S. (1994). Gun control and suicide in Ontario.   American Journal of Psychiatry, 154,  606–608. Center for Mental Health in Schools at UCLA. (2003).  A technical assistance sampler on school interventions to  prevent youth suicide.  Los Angeles, CA: Author. Centers for Disease Control and Prevention. (2002,  June). Surveillance summaries.   Morbidity and   Mortality Weekly Report, 51,  (No. SS-4). Centers for Disease Control and Prevention. (2004). Web-based injury statistics query and reporting system (WISQARS).  Retrieved June 21, 2004, from http:// www.cdc.gov/ncipc/wisqars

Chapter 17: Suicidal Ideation and Behaviors Centers for Disease Control and Prevention. (2005). WISQARS leading causes of death reports, 1999–2002, Retrieved August 3, 2005, from http://webappa.cdc. gov/sasweb/ncipc/leadcaus10.html

Haw, C., Hawton, K., Houston, K., & Townsend, E. (2003). Correlates of relative lethality and suicidal intent among deliberate self-harm patients.  Suicide  and Life-Threatening Behavior, 33,  353–364.

Davis, J. M., & Sandoval, J. (1991).   Suicidal youth: School-based intervention and prevention. San Francisco: Jossey-Bass.

Helsel, D. C. (2001). Tracking the suicidal student.  The  Clearing House, 75 (2), 92–95.

Eckert, T. L., Miller, D. N., DuPaul, G. J., & RileyTillman, T. C. (2003). Adolescent suicide prevention: School psychologists’ acceptability of school-based programs. School Psychology Review, 32,  57–76.

Hjelmeland, H., Hawton, K., Nordvik, H., Bille-Brahe, U., De Leo, D., Fekete, S., et al. (2002). Why people engage in parasuicide: A cross-cultural study of  intentions.   Suicide and Life-Threatening Behavior,  32, 380–393.

Edwards, M. J., & Holden, R. R. (2001). Coping, meaning in life, and suicidal manifestations: Examining  gender differences.  Journal of Clinical Psychology, 59, 1133–1150.

 Jick, H., Kaye, J. A., & Jick, S. S. (2004).  Antidepressants and the risk of suicidal behaviors.  Journal of the American Medical Association, 292, 338–343.

Elliott, S. N., McKevitt, B. C., & DiPerna, J. C. (2002). Promoting social skills and development of socially  supportive learning environments. In S. E. Brock, P. J. Lazarus, & S. R. Jimerson (Eds.),  Best practices  in school crisis prevention and intervention  (pp. 151– 170). Bethesda, MD: National Association of School Psychologists.

 Jobes, D. A., Luoma, J. B., Hustead, L. A., & Mann, R. E. (2000). In the wake of suicide: Survivorship and postvention. In R. W. Maris, A. L. Berman, & M. M. Silverman (Eds.),  Comprehensive textbook of   suicidology    (pp. 536–561). New York: Guilford Press.

Garland, A. F., Shaffer, D., & Whittle, B. (1989). A  national survey of school-based adolescent suicide prevention programs.   Journal of the American  Academy of Child and Adolescent Psychiatry, 28,  931– 934. Glowinski, A. L., Bucholz, K. K., Nelson, E. C., Fu, Q., Madden, P. A., Reich, W., & Heath, A. C. (2001). Suicide attempts in an adolescent female twin sample.  Journal of the American Academy of Child and   Adolescent Psychiatry, 40,  1300–1308. Goldsmith, S. K., Pellmar, T. C., Kleinman, A. M., & Bunney, W. E. (Eds.). (2002).   Reducing suicide: A national imperative. Washington, DC: National  Academies Press. Grunbaum, J. A., Kann, L., Kinchen, S., Ross, J., Hawkins, J., Lowry, R., et al. (2004, May). Youth risk behavior surveillance—United States, 2003.  Morbidity and Mortality Weekly Report, 53  (No. SS02), 1–96. Retrieved July 20, 2004, from http:// www.cdc.gov/mmwr/preview/mmwrhtml/ss5302a1.htm Gutierrez, P. M., Osman, A., & Kopper, B. A. (2000). Suicide risk assessment in a college student population. Journal of Counseling Psychology, 47,  403–413.

Kellermann, A. L., Rivara, F. P., Somes, G., Reay, D. T., Francisco, J., Banton, J. G., et al. (1992). Suicide in the home in relation to gun ownership.   The New  England Journal of Medicine, 327,  467–472. King, K. A., Schwab-Stone, M., Flisher, A. J., Greenwald, S., Kramer, R. A., Goodman, S. H, et al. (2001). Psychosocial and risk behavior correlates of youth suicide attempts and suicidal ideation.  Journal of the American Academy of Child and   Adolescent Psychiatry, 40,  837–846. Lubell, K. M., Swahn, M. H., Crosby, A. E., & Kegler, S. R. (2004). Methods of suicide among persons aged 10–19 years—United States, 1992–2001. Morbidity  and Mortality Weekly Report, 53,  471–473. Retrieved  July 20, 2004, from http://www.cdc.gov/mmwr/ PDF/wk/mm5322.pdf  Maris, R. W., Berman, A. L., & Silverman, M. M. (2000).   The comprehensive textbook of suicidology. New York: Guilford Press. Moscicki, E. K. (1995). Epidemiology of suicidal behavior. Suicide and Life-Threatening Behavior, 25,   22–35. O’Donnell, L., O’Donnell, C., Wardlaw, D. M., & Stueve,  A. (2004). Risk and resiliency factors influencing  237

Children’s Needs III suicidality among urban African American and Latino youth.   American Journal of Community  Psychology, 33,  37–49. Prager, K. (2003).   Health, United States, 2003: With chart book on trends in the health of Americans. Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Ramsay, R. F., Tanney, B. L., Lang, W. A., & Kinzel, T. (2004).   Suicide intervention handbook    (10th ed.). Calgary, AB: LivingWorks. Reynolds, W. M. (1988).  Suicidal ideation questionnaire: Professional manual.   Odessa, FL: Psychological  Assessment Resources. Rutter, P. A., & Soucar, E. (2002). Youth suicide risk and sexual orientation. Adolescence, 37,  289–299. Sandoval, J., & Brock, S. E. (1996). The school psychologist’s role in suicide prevention.  School Psychology  Quarterly, 11, 169–185.

critical review.  Journal of the American Academy of   Child and Adolescent Psychiatry, 27,  675–687. Shaffer, D., Garland, A., & Whittle, B. (1987).  An evaluation of three youth suicide prevention programs in New Jersey. Unpublished report, Division of Child Psychiatry, New York State Psychiatric Institute, Columbia University, NY. Simon, T. R., Swann, A. C., Powell, K. E., Potter, L. B., Kresnow, M., & O’Carroll, P. W. (2001). Characteristics of impulsive suicide attempts and attempters.   Suicide and Life-Threatening Behavior,  32 (Suppl), 49–59. Sloan, J. H., Rivara, F. P., Reay, D. T., Ferris, J. A., & Kellermann, A. L. (1990). Firearm regulations and rates of suicide: A comparison of two metropolitan areas.  New England Journal of Medicine, 322,  369–373. Spirito, A., Valeri, S., Boergers, J., & Donaldson, D. (2003). Predictors of continued suicidal behavior in adolescents following a suicide attempt.   Journal of    Clinical Child and Adolescent Psychology, 32,   284– 289.

Seeley, J. R., Rohde, P., Lewinsohn, P. M., & Clarke, G. N. (2002). Depression in youth: Epidemiology, identification, and intervention. In M. R. Shinn, G. M. Walker, & G. Stoner (Eds.),  Interventions for  academic and behavior problems. II: Preventive and  remedial approaches   (pp. 885–911). Bethesda, MD: National Association of School Psychologists.

U.S. Food and Drug Administration. (2004, March 22). FDA public health advisory. Subject: Worsening depression and suicidality in patients being treated with antidepressant medications.   Retrieved July 25, 2004, from http://www.fda.gov/cder/drug/antidepressants/  AntidepressanstPHA.htm

Shaffer, D., Garland, A. F., Gould, M., Fisher, P., & Trautman, P. (1988). Preventing teenage suicide: A 

U.S. Public Health Service. (1999). The surgeon general’s call  to action to prevent suicide. Washington, DC: Author.

238